Confusion around the recent rollout of three different immunizations to protect against RSV may have led to the errors.
- The
CDC recently issued an emergency alert to clinicians reporting some
pregnant people and young children received the wrong RSV vaccine.
- Vaccine
errors are rare, and no adverse events were reported in this instance.
- Experts
say confusion around the recent rollout of three different immunizations
to protect against RSV may have led to the errors.
- Currently,
two RSV vaccines are approved for use in older adults, with one of these
also approved for use in pregnant people.
- A
third monoclonal antibody treatment is recommended for use in infants up
to 8 months to protect against severe illness.
Vaccine administration
errors are uncommon but may occasionally occur.
When a trio of
immunizations to protect high-risk groups against respiratory syncytial virus (RSV) rolled
out last fall, confusion surrounding the vaccines ensued among patients and
even clinicians alike.
A recent emergency alert released
by the Centers for Disease Control and Prevention (CDC) reports that RSV shots
were wrongfully administered to a small number of pregnant people and young
children. As of January 17, 2024, the alert states that 128 pregnant people
received the wrong RSV shot, and 25 children under 2 received an RSV vaccine
approved for use in adults only.
While any number of vaccine
errors may seem alarming, the CDC notes the errors are “relative to an
estimated 1 million infants protected from RSV either through infant receipt of
nirsevimab or through vaccination of pregnant people.”
Young children, pregnant
people, and older adults are considered most at risk for severe illness from
RSV, a respiratory virus resembling the common cold. Most people recover from RSV in
Abrysvo (Pfizer) and Arexvy (GSK)
are both approved for use in
Currently, there is no RSV
vaccine available to younger children. A
In addition, pregnant
people who receive the maternal Abrysvo vaccine may
pass antibodies to a developing fetus, which may protect a newborn from severe illness after birth.
Clinicians who administered
the wrong RSV vaccines reported them to the Vaccine Adverse Event Reporting
System (VAERS). The vaccine errors did not lead to adverse events,
but the CDC and Food and Drug Administration (FDA) will continue to monitor the
situation.
If you or your child
received the wrong RSV vaccine or you are concerned about getting the right
one, here’s what you need to know to stay safe.
Lack of clarity
around the three different RSV immunizations may have caused some clinicians to
mistakenly administer the wrong shot.
“New vaccines and
treatments can sometimes lead to confusion, especially in busy healthcare
settings,” Dr. Daniel Ganjian, board
certified pediatrician at Providence Saint John’s Health Center in Santa
Monica, CA, told Medical News Today.
To add to any confusion
surrounding the rollout of three different RSV immunizations, Dr. Ganjian noted
the RSV shots have similar names — Abrysvo and Arexvy — which may have
contributed to the mixups.
Dr. Patricia Faraz, board certified OB-GYN at
The Women’s Hospital at MemorialCare Saddleback Medical Center in Laguna Hills,
CA, told MNT that
such vaccine errors could be reduced by clinicians if proper systems were put
into place. For instance, the patient order and vaccine could be verified by
more than one staff member.
“Medications for OB patients should not be stored in
the same refrigerator as non-OB patients to reduce errors as staff members may
not be familiar with these new vaccines, and they are named similarly,” Dr.
Faraz suggested.
Should you be
worried if you got the wrong RSV vaccine?
If you received
a vaccine in error, you should notify your healthcare team and report any
adverse events to VAERS, which helps public
health officials identify and address potential issues with vaccines, Dr.
Ganjian explained.
If you’re concerned your
child may have received a vaccine intended for adults, try to stay calm. You
should contact their pediatrician who “can review your child’s records and
confirm if they received the correct vaccine. If not, they will advise you on
the next steps,” Dr. Ganjian noted.
If a vaccine reaction were
to occur, symptoms should generally subside within 48 hours. If symptoms
persist, contact your doctor right away. “Serious adverse events are very rare
in these situations,” Dr. Ganjian said.
No serious reactions were
reported among pregnant people and children who received the wrong shot.
RSV vaccines are considered
safe and effective when used as intended. No adverse events were reported
during clinical trials of the RSV vaccines for
However, any risks of
adverse events from receiving the wrong RSV shot are not yet known.
“Unfortunately, these vaccines are brand new, and
adverse events in pregnant women are not known with Arexvy,” Dr. Faraz said.
“Over time, adverse events may be reported, and then we
will have a better idea regarding potential side effects or efficacy rates of
the Arexvy, which is indicated for individuals over 60,” she explained.
Signs of adverse reactions to vaccines
The two RSV vaccines and
the monoclonal antibody treatment for young children are not interchangeable.
They should be used only in the high-risk groups for which they are approved.
While no serious adverse
events were reported from this vaccine error, any unusual symptoms after
vaccination should be relayed to your doctor.
According to Dr. Ganjian,
symptoms of adverse reactions may include:
- fever
- redness or
swelling at the injection site
- allergic
reactions (i.e., hives or difficulty breathing)
To ensure you
or your child receive the correct RSV vaccine, experts say it’s important to
ask your doctor questions and get information from reliable sources.
Federal agencies like the
CDC can also provide you with the most accurate and up-to-date information
about RSV vaccines and treatments.
Dr. Ganjian recommended
asking your doctor or vaccine technician for the exact name of the vaccine
you’re wanting to receive.
“For example, if you have a
baby, tell your doctor you want nirsevimab. If you are pregnant, ask for
[Abrysvo],” he said.
“Don’t hesitate to ask your healthcare provider about the vaccine or treatment you’re receiving. Make sure you understand what it is and why you’re getting it. If you have any concerns, double-check the information with your provider or pharmacist before receiving the vaccine.”— Dr. Ganjian, pediatrician.
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